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<br />TE OF NEBRASKA >'> "`
<br />WHEN : THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />:DATE OF.ISStIAIIJCE
<br />10/26/2020
<br />LINCOLN, NEBRASKA
<br />2022018
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<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME {First, Middle, Last, Suffix)
<br />Johnnie Wayne;' Bruns
<br />4. CITY AN¢ STATE OR"TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OFDEATH(Mp, pay, yr.)
<br />October 19, 2020
<br />6. DATE OF BIRTH (Mo., Day,'Yr.)
<br />7. SOCIAL S€CURI'.Y NUMBER
<br />In;50&4040863.A
<br />8b:'FACILITY-NAME.(Ifnot Institution, give street and number)
<br />107 W 23rd Street
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand lslend 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9dS717REETPiND NUMBER
<br />1`07111! 23rd Street'
<br />9b. COUNTY
<br />Hall
<br />88. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />July 24,::J:935::::„:.
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />❑'Hospice Facility
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />8g INSIgE CITY LIINITS
<br />® VEs O No!
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Nancy Ann Harder
<br />11..FATHER'S•NAME tFirst, Middle, Last, Suffix)
<br />•Edwin Bruns
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />Burial ' ❑Donation
<br />0 Cremation ❑ Enfombment
<br />Removat❑Other (Specify)
<br />14a. INFORMANT -NAME
<br />Nancy Ann Bruns
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />12. MOTHER'S -NAME (First, Middle,
<br />Myrtle Josh
<br />16b. LICENSE NO.
<br />1397
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery
<br />Grand Island
<br />Maiden Sumame)
<br />14b. RELATIONSHIP TO OECEDENT
<br />Spouse
<br />16c. DATEs(Mo., pay, Yr.}
<br />October22, 2020
<br />STATE
<br />Nebraska
<br />17a..FUNERALHOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Alf Faiths Funera€;Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. Enter the chain of events- -diseases, :injuries, or complications -hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease orcondition resulting
<br />in'.death)
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />online a.
<br />Erifer the tINDERLVIND CAUSE
<br />(dIseaae or lignivthatinitiated
<br />the events resulting in death)
<br />LAST
<br />a) Non -Traumatic Subdural Hematoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Alzheimer's Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART B. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE;;
<br />❑ Not pregnant within pestyear
<br />Pragnam at:time of deattl:
<br />%N01•pregnafit, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑: Vnknown 1f,Fregnant within the past year
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<br />22a. DATE OF:tNJURY (Mb., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ;❑NO,,
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Acc(dent ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />17b. Zip Code
<br />68$01
<br />APPROXIMATE INTERVAL
<br />onsetto death
<br />2 Weeks
<br />onset to death
<br />4 Years
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES `. lJ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES E] No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Spect
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 19, 2020
<br />CITY/TowN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Oetober 2:1, 2020
<br />23c. TIME OF DEATH
<br />11:19AM
<br />Tad. Toithe blest of my knowledge, death occurred M the time, date and place
<br />and due to•(he"cause(s).stated. (Signa ite and Title)
<br />Richard Fruehlinq, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e, On the basis of examination and/or investigation, in my opinion death oecurnd at
<br />the time, date and place and due to the cause(s) stated. (Signatureand:Title)•
<br />':
<br />25. DID TOBACCO .USE CONTRIBUTE TO THE DEATH?
<br />YES NO 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ba NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES'
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Richard FrueMing, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 21, 2020
<br />CJI
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